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MUR case study: Secondary prevention lipid modification

A patient has some compliance issue around their blood pressure medication

It’s Friday evening and the whole day has been manic. Calamity Friday, as it’s known, is coming to an end. Barry, a regular patient, pops in for his prescription. As you go to fetch his medication you notice an MUR sticker on the bag, which prompts you to offer the service. Barry, 48, is always chatty and promptly agrees.
 

Below is an excerpt from the MUR form:

Medicine

Indication

Compliance

Amlodipine 5mg once in the morning 

For hypertension 

Admits to not taking it all the time due to forgetting to take it in the morning

Simvastatin 40mg once in the evening

Post-MI

Very good fully compliant 

Aspirin 75mg once daily

Post-MI 

Does not take as upsets stomach


On further discussion, you discover that Barry has bought omega-3 capsules since his myocardial infarction (heart attack) two years ago.
 
He also tells you in the past he has taken lisinopril, which caused a cough.
 

Main action points

Issue

Amlodipine: poor compliance 

Recommendation

His blood pressure would need reviewing at the GP practice and his poor compliance should be highlighted to the prescriber. Being 48 years old,  he should be on an Angiotension covnerting enzyme (ACE) inhibitor. Advise Barry to speak to his doctor about potentially taking his blood pressure medication at night alongside his statin, which he is fully compliant with.

Rationale

Poor BP control leads to poor health outcomes. Nice recommends that those under 55 should be on an ACE inhibitor first line. We can see he had a cough with lisinopril, a common side effect of this class of medicine. Nice guidelines recommend to use angiotension II receptor blockers (ARBs) when individuals have an intolerance to ACE inhibitors. The incidence of intractable cough with ARBs is lower, so it may be worth trialling. This would lower his BP and be in line with Nice guidelines.

Issue

Simvastatin 40mg: not the current recommended statin for secondary prevention after an MI.

Recommendation

Explain to Barry that the guidelines for lipids have changed recently. According to the new guidance he should be on a high-intensity statin such as atorvastatin 80mg or 40mg. If Barry wishes to change, he should book in with the GP practice to discuss his options. It is not necessary to switch if he does not want to.  

Rationale

July 2015 saw the new Nice guidance on lipid modification. Those on secondary prevention should be on a high-intensity statin. This includes atorvastatin 80mg or, under certain circumstances, atorvastatin 40mg may be suitable. New guidance does not suggest annual liver function tests once the patient is stabilised on a statin. This means there is no longer a need for fasting before blood lipid checks. Simvastatin 80mg is also termed a high-intensity statin; however, the risk of associated muscle complications are higher when compared with atorvastatin. 

Issue

Omega-3 capsules: no evidence the supplements help

Recommendation

Explain that there is not enough evidence to suggest that these actually lower the risk of having any further heart problems according to the Nice guidelines. However, it is his choice if he wishes to continue. Advise that the current recommendations suggest eating oily fish at least twice a week; this should contain the omega-3 that he is getting in his supplements.

Rationale 

There is scant evidence to recommend omega-3 supplements for lowering CVD risk. However, some epidemiological studies suggest otherwise (Marik 2009). Barry would not be prescribed these on the NHS, and it would therefore be his own choice to continue to buy these. Supplements are not recommended according to clinical care summaries produced by Nice.

Issue

Aspirin 75mg: not taking due to stomach upset

Recommendation

Explain it is important to take a medicine such as aspirin as it “thins the blood” to lower the risk of another MI. However, if this medication is not suiting him, suggest that he could speak to his doctor about trying an alternative. 

Rationale
According to Nice, he should be offered an alternative antiplatelet if the aspirin is not suiting him. He could be prescribed clopidogrel or prasugrel, which both have a lower side effect profile than aspirin.


As you are about to offer Barry lifestyle advice, he makes you aware he needs to be going and promises to take your advice about the medication and make an appointment with his GP. You hand him a leaflet on lifestyle advice for those who have suffered a cardiovascular event. As he takes it, he tells you he regularly attends the heart care group and is well-versed with lifestyle advice.

 
What is the lifestyle advice for someone who has had an MI?
  • Stop smoking
  • Daily fat intake should be 30% of total energy. Saturated fats (mainly animal fats) should be less than 7%
  • Use olive oil or rapeseed oil spreads as a substitute for butter
  • At least five portions of fruit or vegetables a day
  • At least two portions of oily fish a week
  • Handful (approximately 30g) of nuts and seeds (unsalted) 4-5 times per week
  • Salt intake less than 6g day
  • Aim for least 30 minutes of moderate intensity exercise a day
  • A max daily alcohol intake of two units for women and three for men, with at least two-alcohol free-days in any given week

The British Heart Foundation has a list of heart care groups, which can be found at www.bhf.org.uk/heart/how-we-can-help/heart-support-groups

 
 
References

Marik PEVaron J. Omega-3 Dietary Supplements and the Risk of Cardiovascular Events: a Systematic Review. Clin Cardiol. 2009 Jul;32(7):365-72
www.ncbi.nlm.nih.gov/pubmed/19609891
www.bhf.org.uk/heart-health/how-we-can-help/heart-support-groups

1 Comments
Question: 
What do you think about this MUR?

Shahid Bashir, Locum pharmacist

A very uptodate and relevant MUR case study. The MUR case studies should be of this standard and not the standard regurgitation of basic knowledge that we all should know.

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